Meningitis due to Bacillus cereus: A case report and review of the literature.

Bacillus cereus is infrequently associated with invasive central nervous system (CNS) disease. Infection is associated with conditions that lead to reduced host immunity and provide direct access to the CNS, such as spinal anesthesia and ventricular tubes and shunts. A case of ventriculitis secondary to B cereus in a patient receiving intrathecal chemotherapy is reported, along with a review of the current literature. B cereus can colonize medical devices, thus posing a risk for invasive disease. Despite aggressive treatment with broad-spectrum anti-infectives, the mortality of CNS invasive B cereus is high. Clinicians should not dismiss Gram-positive rods resembling Bacillus species from normally sterile sites as contaminants in critically ill patients. Appropriate antibiotic therapy should be promptly initiated to limit morbidity and mortality.Bacillus cereus is infrequently associated with invasive central nervous system (CNS) disease. Infection is associated with conditions that lead to reduced host immunity and provide direct access to the CNS, such as spinal anesthesia and ventricular tubes and shunts. A case of ventriculitis secondary to B cereus in a patient receiving intrathecal chemotherapy is reported, along with a review of the current literature. B cereus can colonize medical devices, thus posing a risk for invasive disease. Despite aggressive treatment with broad-spectrum anti-infectives, the mortality of CNS invasive B cereus is high. Clinicians should not dismiss Gram-positive rods resembling Bacillus species from normally sterile sites as contaminants in critically ill patients. Appropriate antibiotic therapy should be promptly initiated to limit morbidity and mortality.

Le Bacillus cereus s'associe rarement à une maladie invasive du système nerveux central (SNC). L'infection est liée à des pathologies qui réduisent l'immunité de l'hôte et procurent un accès direct au SNC, telles qu'une rachianesthésie et des tubes et dérivations ventriculaires. Les auteurs rendent compte d'un cas de ventriculite secondaire à un B cereus chez un patient sous chimiothérapie intratéchale et présentent une analyse des publications à jour. Le B cereus peut coloniser les dispositifs médicaux, posant ainsi un risque de maladie invasive. Malgré un traitement énergique au moyen d'anti-infectieux à large spectre, la mortalité attribuable au B cereus invasif du SNC est élevée. Les cliniciens ne devraient pas rejeter la possibilité que des bacilles Gram positif évocateurs d'espèces de Bacillus dans les foyers normalement stériles soient des contaminants chez les patients gravement malades. Il faudrait amorcer rapidement une antibiothérapie pertinente pour limiter la morbidité et la mortalité.

Randomized Quality Improvement Trial of Opting-In Versus Opting-Out to Increase Influenza Vaccination Rates during Pregnancy.

Introduction Despite strong recommendations, only 40.6% of pregnant women attending two prenatal clinics were vaccinated against influenza during the 2009 pandemic. We tested whether an opting-out approach would improve vaccine uptake. Methods We conducted a randomized quality improvement (QI) trial to compare opting-out with conventional opting-in consent for influenza immunization. Women age ≥ 18 years attending the University of Texas Health Science Center at Houston (UTHealth) or UT-Medical Branch (UTMB) prenatal clinics during the 2010-2011 influenza season, were eligible. Results We enrolled 280 women (140 UTHealth, 140 UTMB). Both groups had similar mean age (26.0 ± 5.5 years), mean gestational age (19.4 ± 9.5 weeks), and percent with underlying health conditions (20.7%). Vaccination rates with opting-in and opting-out were similar among all (83 vs. 84%), UTHealth (87 vs. 93%), and UTMB patients (79 vs.76%) ( p > 0.05). In subsamples of patients assessed, consent strategy did not significantly affect maternal recall of information provided. Conclusion While prenatal influenza vaccination uptake doubled from the 2009-2010 influenza season, opting-out did not perform better than opting-in, a conclusion opposite that we would have reached had this been a nonconcurrent trial. Vaccination rates dropped posttrial; hence, continued research is needed to increase the prenatal influenza immunizations.

Continued non-compliance with the American College of Surgeons recommendations to decrease infectious exposure in the operating room: why?

BACKGROUND: The American College of Surgeons (ACS) Statement on Sharps Safety recommends the use of double gloving (DG), hands-free zone (HFZ), and blunt-tip suture needles (BTSN) in the operating room to decrease needlestick injuries. Despite this endorsement, compliance is low. This survey determined the perceptions, attitudes, and barriers to compliance with these guidelines. METHODS: A survey using a voluntary convenience sample of surgical staff members in which queries related to understanding of the ACS recommendations were posed. A total of 107 of the 324 surveys were completed and returned, for a response rate of 33%. Most respondents were residents (64%) or attending surgeons (29%). RESULTS: Respondents were most familiar with recommendations for DG (58% of residents and 68% of attendings) and HFZ (61% for both groups) but less so for BTSN (48% of residents and 52% of attendings). More than 50% of the staff believed that DG decreased the risk of needlesticks, yet fewer than half used DG more than 75% of the time. Half believed that HFZ protected from sticks, yet fewer than 10% used it at least 75% of the time. Fewer than 50% believed that BTSN minimizes the risk of injury, with fewer than 10% of respondents using them at least 75% of the time. Reasons for non-compliance included decreased tactile sensation with DG, lack of training with HFZ, and lack of availability of BTSN. CONCLUSIONS: To improve compliance with the ACS recommendations, institutions must improve awareness of the guidelines and the benefits associated with compliance and remove barriers to their incorporation into standard practice.

A crossover trial of antimicrobial scrubs to reduce methicillin-resistant Staphylococcus aureus burden on healthcare worker apparel.

BACKGROUND: The impact of antimicrobial scrubs on healthcare worker (HCW) bacterial burden is unknown. Objective. To determine the effectiveness of antimicrobial scrubs on hand and apparel bacterial burden. DESIGN: Prospective, crossover trial. SETTING AND PARTICIPANTS: Thirty HCWs randomized to study versus control scrubs in an intensive care unit. METHODS: Weekly microbiology samples were obtained from scrub abdominal area, cargo pocket, and hands. Mean log colony-forming unit (CFU) counts were calculated. Compliance with hand hygiene practices was measured. Apparel and hand mean log CFU counts were compared. RESULTS: Adherence measures were 78% (910/1,173) for hand hygiene and 82% (223/273) for scrubs. Culture compliance was 67% (306/460). No differences were observed in bacterial hand burden or in HCWs with unique positive scrub cultures. No difference in vancomycin-resistant enterococci (VRE) and gram-negative rod (GNR) burden was observed. A difference in mean log methicillin-resistant Staphylococcus aureus (MRSA) CFU count was found between study and control scrubs for leg cargo pocket (mean log CFUs, 11.84 control scrub vs 6.71 study scrub; [Formula: see text]), abdominal area (mean log CFUs, 11.35 control scrub vs 7.54 study scrub; [Formula: see text]), leg cargo pocket at the beginning of shift (mean log CFUs, 11.96 control scrub vs 4.87 study scrub; [Formula: see text]), and abdominal area pocket at the end of shift (mean log CFUs, 12.14 control scrubs vs 8.22 study scrub; [Formula: see text]). CONCLUSIONS: Study scrubs were associated with a 4-7 mean log reduction in MRSA burden but not VRE or GNRs. A prospective trial is needed to measure the impact of antimicrobial impregnated apparel on MRSA transmission rates.

Achromobacter species endocarditis: A case report and literature review.

Endocarditis due to Achromobacter species is a rare, yet serious, endovascular infection. Achromobacter species infective endocarditis is associated with underlying immunodeficiencies or prosthetic heart valves and devices. A case of prosthetic pulmonary valve endocarditis secondary to Achromobacter xylosoxidans subspecies denitrificans is described in the present report. This life-threatening infection was successfully treated with combined valve replacement and prolonged antibiotic therapy. A Medline/PubMed literature review of Achromobacter endocarditis was also performed. Achromobacter species are an uncommon, yet important, cause of nosocomial endocarditis. Given the significant associated morbidity and mortality, along with a high degree of intrinsic antibiotic resistance, Achromobacter species infective endocarditis remains a clinical treatment challenge.

Invasive sinonasal disease due to dematiaceous fungi in immunocompromised individuals: case report and review of the literature.

Invasive dematiaceous fungal sinusitis is an uncommon and aggressive disease in immunocompromised individuals. We report a unique case of invasive Exserohilum sinusitis in a pregnant, immunocompromised woman. After treating the woman with pregnancy-induced aplastic anemia and invasive Exserohilum sinusitis and pulmonary disease, we performed a Medline/PubMed review of invasive dematiaceous fungal sinonasal disease in immunocompromised individuals. Twelve cases of proven and one case of probable invasive sinonasal dematiaceous fungal disease in immunocompromised patients are reported in the English-language literature. The majority of patients had underlying hematological conditions. The crude mortality was high, with over half of the patients dying from presumed complications of the underlying immunosuppression. Successful outcomes were associated with surgical debridement, aggressive antifungal use, and a reduction of immunosuppression. The optimal treatment for immunocompromised patients with invasive dematiaceous fungal disease is not known. The role of newer triazoles, posaconazole and voriconazole, appears promising, however more clinical data are needed. Definitive diagnosis requires tissue biopsy and successful treatment is associated with reduction of immunosuppression, aggressive surgical debulking, and systemic antifungal therapy.

Treatment of severe cases of pandemic (H1N1) 2009 influenza: review of antivirals and adjuvant therapy.

Three worldwide influenza pandemics were reported in the 20th century: in 1918, 1957 and 1968. All three pandemics were caused by different sub-types of Influenza A viruses: H1N1, H2N2 and H3N2 respectively. In early March 2009, the first cases of influenza -like illness (ILI) were reported from Mexico. This strain was identified as influenza A/ H1N1 strain. Pandemic (H1N1) 2009 influenza most commonly causes a self-limited illness, however, significant morbidity and mortality were reported in the young, the obese and in pregnant women. The drugs of choice for treatment and prophylaxis of pandemic (H1N1) 2009 influenza are the neuraminidase inhibitors, Oseltamivir and Zanamivir. While a few cases of Oseltamivir-resistance are reported, these isolates still retained their susceptibility to the inhaled Neuraminidase inhibitor, Zanamivir. Pandemic (H1N1) 2009 influenza virus is routinely resistant to the adamantanes: Amantadine and Rimantadine. These agents should not be used for the treatment or prophylaxis of pandemic (H1N1) 2009 influenza. The FDA recently approved the emergency use of Peramivir, an intravenous neuraminidase inhibitor, for the treatment of patients with severe influenza. We discuss the use of available antivirals, as well as the effectiveness of adjunctive therapies with immunomodulatory and anti-inflammatory agents, such as immunoglobulins and statins, for the treatment and management of patients with severe H1N1 influenza. This review summarizes the recent patents for the use of antivirals in treatment of severe influenza.

Nasal carriage of inducible dormant and community-associated methicillin-resistant Staphylococcus aureus in an ambulatory population of predominantly university students.

BACKGROUND: We studied risk factors for nasal colonization with inducible dormant methicillin-resistant Staphylococcus aureus (ID-MRSA) and community-associated MRSA (CA-MRSA) in a cohort of predominantly university students. METHODS: Nasal surveillance cultures were performed in student health and ambulatory clinics. Molecular features were identified and risk factors for CA-MRSA and ID-MRSA colonization were determined by logistic regression. RESULTS: Of the 1000 participants, 89% (n = 890) were university students. Sixty-four percent were female, 59% Caucasian. The mean age was 23.5 years; 1.6% (n = 16) were CA-MRSA and 1.4% (n = 14) were ID-MRSA colonized. Fifteen (94%) of the CA-MRSA strains were PFGE type IV. pvl (Panton-Valentine leukocidin gene) positivity was 75% in CA-MRSA and 57% in ID-MRSA. ID-MRSA isolates were pulsed-field gel electrophoresis (PFGE) type I, 7%; type II, 14%; type V, 7%; and type IV, 71%. CA-MRSA SCCmec classification was 94% type IV and 6% type V. Risk factors for carriage of CA-MRSA were older age (OR 1.046, p=0.040) and dog ownership (OR 1.450, p=0.019). Single family home (OR 0.040, p=0.007) was a protective factor. There were no significant variables of association found for ID-MRSA colonization. CONCLUSIONS: ID-MRSA/CA-MRSA colonization was low. Most isolates were PFGE types IV and II, pvl-positive and susceptible to several antibiotics. Older age and dog ownership were risk factors for CA-MRSA. Future studies are needed to assess the impact of ID-MRSA carriage.

Trial of universal gloving with emollient-impregnated gloves to promote skin health and prevent the transmission of multidrug-resistant organisms in a surgical intensive care unit.

OBJECTIVE: To compare the efficacy of universal gloving with emollient-impregnated gloves with standard contact precautions for the control of multidrug-resistant organisms (MDROs) and to measure the effect on healthcare workers' (HCWs') hand skin health. DESIGN: Prospective before-after trial. SETTING: An 18-bed surgical intensive care unit. METHODS: During phase 1 (September 2007 through March 2008) standard contact precautions were used. During phase 2 (March 2008 through September 2008) universal gloving with emollient-impregnated gloves was used, and no contact precautions. Patients were screened for vancomycin-resistant Enterococcus (VRE) and methicillin-resistant Staphylococcus aureus (MRSA). HCW hand hygiene compliance and hand skin health and microbial contamination were assessed. The incidences of device-associated infection and Clostridium difficile infection (CDI) were determined. RESULTS: The rate of compliance with contact precautions (phase 1) was 67%, and the rate of compliance with universal gloving (phase 2) was 78% (P = .01). Hand hygiene compliance was higher during phase 2 than during phase 1 (before patient care, 40% vs 35% of encounters; P = .001; after patient care, 63% vs 51% of encounters; P < .001). No difference was observed in MDRO acquisition. During phases 1 and 2, incidences of device-related infections, in number of infections per 1,000 device-days, were, respectively, 3.7 and 2.6 for bloodstream infection (P = .10), 8.9 and 7.8 for urinary tract infection (P = .10), and 1.0 and 1.1 for ventilator-associated pneumonia (P = .09). The CDI incidence in phase 1 and in phase 2 was, respectively, 2.0 and 1.4 cases per 1,000 patient-days (P = .53). During phase 1, 29% of HCW hand cultures were MRSA positive, compared with 13% during phase 2 (P = .17); during phase 1, 2% of hand cultures were VRE positive, compared with 0 during phase 2 (P = .16). Hand skin health improved during phase 2. CONCLUSIONS: Compared with contact precautions, universal gloving with emollient-impregnated gloves was associated with improved hand hygiene compliance and skin health. No statistically significant change in the rates of device-associated infection, CDI, or patient MDRO acquisition was observed. Universal gloving may be an alternative to contact precautions.